Dance of the Home Health Visit

A Step in the Right Direction

Thoughts About Change

The more things change, the more they remain the same. - Alphonse Karr (Klein, 2002)

It has been said that change is the only constant. Certainly, if one lives long enough, one witnesses much change for the good and for the bad, in the home, in society, and in academia.

Faculty struggle for ways to keep their technologically-savvy students engaged, while they are adapting to the technology themselves. Many times, students help instructors who are stuck at the front of the room, trying to bring that fancy Power-Point lecture, which they have laboriously prepared, to those two large screens on either side of the room. The dance class may have changed, but the body movements are the same. As instructors, we are there to teach and the students are there to learn. However, it would seem to this faculty member that today,nstudents want to be entertained while they are taught the lesson.

This faculty member is most likely to repeat traditional steps that were enacted for her when she was learning; methods that I am most familiar with, from when I was a student in the classroom and learning my own lessons. As I thought about the methods that were used to teach me, it was so evident that I never remembered being engaged as a young child or a young adult in the classroom. My job was to learn all the information that was verbally given to me. The teacher’s job was not to entertain me, but to teach me. My educational dance was a two-step. The teacher delivered and I received the lesson.

Things Have Changed

There is nothing permanent except change. - Heraclitus (Klein, 2002)

Today, the academic environment has changed. The millennial student is a multitasker; society has provided him or her with the tools to excel at being a multitasker. She or he owns a computer, cell phone, iPod and Blackberry. While faculty may be still wondering what an iPod and Blackberry do and why they are important? Students want their lectures posted on Blackboard and they want them posted BEFORE the class. They want study guides. They want reality. Even though the dance in academia has changed, the student is still there to learn. The rhythm for students is different than ours, but it is still our job to prepare them for the recital at the end of the semester. In other words, the methods need to change but the end results must be the same. Students need to learn.

As an instructor, I search for meaningful ways to engage my senior nursing students, ways that will encourage them to become engaged as active learners. Ways that will help students remember the information without boring them, and without having them suffer through another traditional lecture where I talk and they listen and take notes. I realized it was time to initiate an educational dance that uses the same body movements with different steps and different music.

Erbin-Roesemann & Simms, (1997, p.184) indicated that locus of control is vital in understanding individual responsibility for learning. This one statement alone led me in a distinct direction away from my traditional lecture to a more eventful one and, judging by the comments of the students after class, one that was meaningful for them, as it put them in control.

Time to Change

Life is change . Growth is optional. Choose wisely. - Karen Kaiser Clark (Klein, 2002)

The lecture content was Home Health Nursing, so I thought there would be no better way to inform and engage them in home health than to have them take part in a home health visit, in front of the room, without advance notice. Of course, I had posted the skit on Blackboard; however, they were not aware that they would be starring in the skit, and in the process, enacting their own learning process and method. The Learning Objectives for the class were as follows:

• Observe the structure of assessment in the home setting
• Recognize the needs of a chronic, homebound client
• State the meaning of the term red flag in the home environment
• Explain the effects of living alone for a homebound, elderly client
• Recognize that teaching is a vital, major part of home health nursing.

I brought four, easily transported props with me to class: a stethoscope and nursing home visiting bag for the nurse, a shawl for the client, and a baseball cap with the letters FBI imprinted in large letters on the front, for the hard-to-manage daughter. The auditorium was freezing cold as maintenance was having difficulty with the thermostat that day. When I asked for volunteers for our new venture, not one student raised a hand, so I picked the student that was shivering from the cold room, and made her the client, so that she could warm up by wearing the patient’s shawl.

The student that I chose to be the nurse was a student who always sat at the far back of the room, alone, from class-to-class and did not interact with any other students. Whenever I called on her during class, though, she was bright and appropriate. By the time I had chosen the two volunteers, a third student raised her hand and offered to be the hard-to-manage daughter, the one who would wear the FBI hat. She was surprised as she put it on her head to see that under the large FBI letters, it said, Firm Believer in Jesus, but that caused her to go into the role immediately. She was the strict, religious, family member who did not want to hear what the nurse had to say. And the art of the dance ensued.

Community Home Health Skit

click on the image below to enlarge it

click on the image above to enlarge it

Discussion Questions

1. What is the significance of the home health nurse placing a call in advance to announce her visit?
2. Several red flags are indicated in this scenario, especially at the beginning. What are they?
3. What is the significance of the nurse asking Miss Althea for permission to conduct the home health visit in the presence of her daughter? What could the nurse do if the client did not want the visit conducted in the presence of her daughter? What is the significance of the daughter’s attitude problem? Who is in charge in this household?
4. What is the significance of calling the client ‘Miss Althea and the daughter, Miss Cheryl?
5. What is the importance to know when caring for clients who are living with chronic disease?
6. What facts in this scenario indicate that the nurse should do much-needed teaching in this household?
7. What teaching could the home health nurse do regarding Lasix/furosemide? What dietary suggestions could the nurse make?
8. What teaching could the nurse provide regarding the client’s self-administration of Lanoxin?
9. Who is the Case Manager of this case? What is the significance of the aide having the client sign the home health form without providing any care?
10. What could the nurse teach regarding proper disposal of lances and syringes in the home setting?
11. The nurse needs to ask and record when the client’s next MD visit is every time she visits. Why?
12. The client does not seem to be aware of the negative significance of going barefoot in a cluttered environment (especially since she is diabetic). What teaching could the unregistered nurse (RN) provide? What referral could be made?

Discussion Answers

Scroll to the bottom of the page to view the discussion question answers.

A Change for the Better

If you realize that all things change, there is nothing you will try to hold onto. - Tao Te Ching (Klein, 2002)

The students enacting the skit were wonderful! The client, tightly wrapped in her shawl, was needy; the nurse was trying to make it work with the patient and the difficult daughter, and the daughter just about stole the show. They were itterbugging and doing the ballet. They used body language, facial expressions, hand movements, and tone of voice to make their points within the skit. They moved around the front of the room, did not give each other the slightest break, and stayed within their roles. The audience of students in the auditorium shook their heads in disbelief as the daughter would not put Thunder, the dog, outside and looked stunned as she did not care if the client took her Lasix, as she knew that she would be the one cleaning up the client when she wet herself. The students were horrified that the daughter had administered the client’s morning insulin and had not fed her yet!

They were empowered: the individual student and the group, by my providing an environment that was designed to nurture continuous learning (Erbin-Roesemann & Simms,1997, p.183). The verbally aggressive daughter, even adlibbed a few times, causing the students in the audience to clap and howl. Students were provided a printed copy of the skit via Blackboard, and the skit was projected on two screens overhead. I had a few hard copies available for them, and students felt free to follow along with the printed word or just view the skit, and listen; as a play was being performed for them in front of the room. Students were free to change seats for their comfort, and a few students felt free to call out suggestions for their costudent actors in front of the room. They were enjoying themselves, being creative, and learning in the process.

As the faculty member, I left the whole skit to the students. According to Bevis, the teacher’s main purpose, beyond the minimal activity of ensuring safety, is to provide the climate, the structure, and the dialogue that promote praxis (2000, p.173). I had done all three; the rest was up to them. I enjoyed my part, as a member of the audience with the rest of the class.

Change is Inevitable

I saw an angel in the block of marble and I just chiseled ‘til I set him free. - Michelangelo (Klein, 2002)

Pertinent questions were presented by the students after they clapped enthusiastically for their teammates who had performed for them.

• Why did the nurse call the patient and daughter Miss and then use their first names?
• Why did the daughter need to put the dog in another room or outside (even if the nurse loves dogs)?

At the conclusion of the skit, I presented questions pertaining to the home health skit to students. Appendix B has these questions in the order that we worked on them. As an instructor, I must admit that I was wowed by my students’ wonderful treatment of the client, their cultural sensitivity, and their therapeutic use of self regarding the client. I was a dance instructor and my ballerinas had performed wonderfully.

What also amazed me, however, was that several senior nursing students did not know the signs of Digoxin toxicity, or the importance of teaching clients who are on Lasix to supplement their diets with a source of potassium daily, if not taking a potassium supplement. When they viewed the side effects of Digoxin through the eyes of the client, however, they got it. When we discussed an acronym for sources of potassium, it was easier for them to remember: BAPSCO refers to bananas, apricots, potatoes, prunes, spinach, cranberries, chicken and orange juice.

Creation of a Concept Map

The teacher’s role is to nurture the learner: to nurture the ethical ideal, to nurture the caring role, to nurture the creative drive, to nurture curiosity and the search for satisfying ideas, to nurture assertiveness and the spirit of inquiry together with the desire to seek dialogue about care, and to be available for that dialogue. (Bevis, 2000, p.174)

Then, as any good instructor is prone to do, I wanted to put this information in a different format for them. They needed to understand the necessary preparation and process of conducting a visit to a client’s home. When they entered the home, they needed to figure out, Who’s in charge? Much of the teaching would need to be directed toward this individual. Payne has stated that the mother has the most powerful position in the society if she functions as a caretaker (2005, p.51). Who was in control in this home since the mother was ill and the daughter was the caretaker? They needed to think about Maslow’s Hierarchy of Needs, (Videbeck, 2006, pp.56-57) not only those pertaining to the client, but also those of the home health nurse in community. For example, where does one find a restroom in community? How does a home health nurse practice safety in the community? This would naturally fall under Maslow’s safety and security needs.

Home health nurses need to focus on their communication skills. According to Rice (2001, p.27), effective communication fosters good working relationships with the patient / caregiver despite differences in educational levels and religious and/or ethnic backgrounds. Many of the students in this class had never dealt with problems of health disparities associated with poverty. This meant that they needed to incorporate ways of communicating and teaching that were congruent with the background of the client. Finally, they needed to realize that client education is a main part of home health nursing. If they do not know the answer to one of their client’s questions, the problem is not in not knowing, it is in not offering to find out the information for the client. Students needed to think about the professional care of the client, including client education, as well as cultural competency, medication management, pain assessment, and health promotion, and disease prevention.

The students enjoyed themselves immensely during this entire learning process. In addition, they remained after class to discuss the skit and I received good evaluations of the class. They had danced the nursing method and the process of a home health visit, while enacting a skit in front of the classroom. Next time, I am thinking about dressing up as my Italian Grandmother for a lecture on cultural sensitivity. For this author, that memory will never change.

Acknowledgment

Dedicated to Lynn Kelly, Ph.D., Widener University in Chester, who has encouraged my writing from the beginning.

references

• Bevis, E. (2000). Teaching and learning: The key to education and professionalism. In Toward a caring curriculum. A new pedagogy for nursing. Em Olivia Bevis & Jean Watson. U.S.A.: Jones & Bartlett Publishers, Inc.
• Erbin-Roesemann, M., & Simms, L. (1997). Work locus of control: The intrinsic factor behind empowerment and work excitement. Nursing Economics / July- August 15, 4.
• Erickson, H. (2007). Concept-based curriculum and instruction for the thinking classroom. California: Corwin Press.
• Klein, A. (2002). Winning words. Quotations to uplift, inspire, motivate and delight. N.Y. Portland House.
• Payne, R. (2005). A framework for understanding poverty. (4th ed). Highlands: Tx: aha! Process, Inc.
• Rice, R. (2001). Home care nursing practice. Concepts and application. St. Louis: Mosby, Inc.
• Videbeck, S. (2006). Psychiatric mental health nursing. (3rd ed). Philadelphia: Lippincott Williams and Wilkins.